Provider Demographics
NPI:1497718233
Name:MANCUSO, PAUL ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ANTHONY
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 N ORANGE AVE STE 240
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4641
Mailing Address - Country:US
Mailing Address - Phone:407-303-2615
Mailing Address - Fax:
Practice Address - Street 1:2501 N ORANGE AVE STE 240
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4641
Practice Address - Country:US
Practice Address - Phone:407-303-2615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90970208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271059500Medicaid
FLP00316596 RAILROADMedicare PIN
FL48307XMedicare PIN
FLI20897Medicare UPIN
FL48307ZMedicare PIN